Archive for January, 2010

This week’s issue of the DM Update is all about the heart and keeping it healthy. Discover the link between COPD and heart function, as well as the risk of heart disease among America’s youth. And our prevention story for this week answers the following question about reducing heart attack risk: should treatment be tailored toward an individual’s heart attack risk or cholesterol levels?

Dr. Craig Samitt, president and CEO of Dean Health System, lists five essential strategies that can lead to a successful ACO in the healthcare industry.

The first strategy for a successful accountable care organization (ACO) is effective recruiting. We all have a tendency to fill a spot just because a spot is available. When one of our doctors leaves, we replace them with anyone who has the technical skills. The same thing occurs with staff. We are being a whole lot more selective than that. We feel that if we make the right hiring decisions in the first place, it saves us effort and turnover and we avoid staffing problems down the line.

Our second strategy is to create incentive systems that are aligned. Much of healthcare reform has to do with this as well. How well are physicians and staff and management in your organization aligned with the vision of your organization? Are we paying our staff and physicians to deliver better care at a lower cost, not just more care? At Dean, in essence, we have sought to redesign our compensation methodologies and our incentives for staff and management to deliver on better care at a lower cost.

Strategy three is about focusing on the customer. With all due respect to physicians, we have been a very physician-centric industry. Frankly, it is shifting to a consumer-centric industry. Are we delivering the product that consumers want, and are we focusing on service?

Strategy four is all about measurement. How many organizations use balance scorecards and dashboards, and how many can arm physicians with the information they need about their practices at the point of care? How many companies know how well they are doing in the service quality access arena? A June 1, 2009 article in the New Yorker by Atul Gawande talked about the differences in quality. Some of the markets that had very low quality weren’t even aware that they had low quality per the Dartmouth Atlas. How well do we share information and metrics to show how we are doing and to allow physicians to compare themselves to other physicians? For example, a scorecard that we shared when I was at Fallon Clinic compared all of the clinical units against each other for all of the elements of the patient satisfaction survey. We gave them A through F for all of the major questions. You can be sure that those departments that were getting Fs were reaching out to those who were getting As to understand what they were doing differently.

Strategy five is about reengineering processes’ and one example is the use of Lean Six Sigma. But, it doesn’t even have to be as sophisticated as that. It can just be basic process redesign. When we think of a medical home, we think of this as primary care redesign. We are looking at what we need our primary care practices to deliver on and reengineering the practices so that they make sense. We want to take our PCPs off of the treadmill that they are on and recognize what we really need PCPs to do, which is to focus on population health.

This week we’re talking about trends that could transform healthcare. In separate stories, learn why the doctor will see you now (at least in California) and maybe even in your car. Besides these consumer-centric concepts, this issue of the Healthcare Business Weekly Update also offers a blueprint for a successful accountable care organization (ACO). Loosely defined, ACOs are a set of providers associated with a defined population of patients that is accountable for the quality and cost of care delivered to that population.

According to healthcare consultant William DeMarco, “through technology, these small groups can link together and act, think and leverage themselves as a larger group, giving them a reward and also an asset value they didn’t have before. This also allows them to coordinate services virtually between the medical group and the hospital.”

Still haven’t taken our medication adherence survey? You’ll miss out on strategies from the 100 healthcare organizations that already have. There’s still one week left to take the survey and receive an e-summary of compiled results.

According to a study published this month in JAMA, progress has been made in reducing the rate of obesity in the U.S. In this week’s issue, you’ll learn about another recommendation for reducing obesity rates from researchers in Oregon. Also, discover whether or not obesity is a bigger threat to quality of life than smoking, and some encouraging news about obesity rates among young children.

Mary Cooley, manager of case and disease management at Priority Health, describes a discharge protocol that is preventing hospital readmissions among patients with cardio vascular conditions.

Our heart failure initiative sprang from our work in 2008 with cardiovascular conditions. Heart failure is one of those top readmission diagnoses for Medicare. We are following the Institute for Healthcare Improvement (IHI) Getting Started for Heart Failure Guide, which says that, “patients must be seen within five days of discharge.” We’re promoting that across our network of providers; the patient is seen in the office to review medications, any early symptoms, the patient’s progress since hospitalization and any questions they might have. We feel that that’s been a key ingredient to our success.

We want to be sure that we empower the patient to be an active participant or an active consumer in their healthcare. We want them to communicate their healthcare concerns and not wait until things get out of hand and an ER visit or an inpatient hospitalization is warranted.

One important concept is to not only discuss the red flags of management and document them in the personal health record (PHR), but to employ “teachback” strategies so that we’re sure that this is all in concert with our health literacy efforts. We want to be comfortable that the patient has heard what we have said, has been able to process that information and has been able to teach that back to us in a way that’s meaningful for them. That will serve them well in managing their condition moving forward.

We also want to not only address current concerns but also anticipate any needs and concerns, and to be proactive. Discuss with the patient that they should talk about their symptoms and any side effects of medication when they see their physician. Not necessarily to stop that medication, but to call the physician first and discuss what’s going on and maybe how that treatment plan can be remedied based on their current effects of the treatment protocols. And also, not only when to call the physician, but who to call. These patients have multiple comorbidities and when they are coming out of the hospital with many different symptoms, they don’t always know who to contact. It’s very important to say who is on first base and who to call when and if you’re having difficulty.

Marijuana is in the air. Last week, the Garden State became the fourteenth in the union to approve the use of medical marijuana, while the Golden State took the first steps toward legalizing the drug for everyone. While it’s unlikely that the California bill will come to fruition, the public safety committee of the state assembly voted 4-3 on a measure that would tax and regulate marijuana in the same way alcohol is controlled.

And in a first-run movie I saw last week, a pair of 50-somethings smoke a joint before attending a party at the home of one of their children. Hilarity ensues and their children are rightly mortified. Hollywood may not be so far off the mark. In a featured story in this week’s Healthcare Business Weekly Update, SAMHSA reports on a dramatic increase in levels of illicit drug use among aging baby boomers that is likely to strain existing substance abuse treatment services in the years to come.

On the flip side, healthcare companies recognize the value of proper adherence to a medication regime. In the first week of our survey on medication adherence, more than 60 companies have already told us about the individuals and conditions targeted by their medication adherence programs as well as the strategies, technologies and tools that are producing results in this area. It’s not complicated — take the survey by January 31 and get a free e-summary of these results.

With the recent news that people with severe depression receive more of a benefit from antidepressant medication than people with mild or moderate depression, this week’s issue examines other aspects of this particular mental illness. Discover the link between sleep and depression, the risks of depression during pregnancy and some surprising disparities in depression care.

The consequences of untreated or inadequately treated depression are significant; therefore, adherence to antidepressant medication is very important. Be sure to take this month’s e-survey on medication adherence by January 31  you’ll receive a summary of compiled results and learn how your peers are improving medication adherence.

Advice from a multi-payor medical home pilot: get a patient registry and start using it. It’s the single tool that can help transform practices into a medical home, promote quality improvement and deliver evidence-based care, recommends Julie Schilz, IPIP and PCMH manager for the Colorado Clinical Guidelines Collaborative in a new podcast — even more effectively than current electronic medical records on the market.

Registries are collections of secondary data related to patients with a specific diagnosis, condition, or procedure. Registries range in simplicity from a collection of paper cards maintained by an individual physician to simple spreadsheets accessible by a small group of physicians to complex databases accessed online across multiple organizations.

Many of the physician practices in Colorado’s year-old medical home pilot already have EMRs but are still doing double data entry into registries in order to generate the reports they need to improve care management and delivery, says Schilz, who will provide an update on the Colorado Multi-Payor Medical Home Pilot in an upcoming webinar. The registry allows practices to better understand its population, perform outreach to patients, verify that it is practicing in conjunction with evidence-based guidelines and generate valuable reports that let them know how they’re doing, Schilz notes.

The lack of a reporting feature is a common complaint among physicians using EMRs as well as a significant barrier to meeting CMS’s proposed objectives for meaningful use of EMRs, finds a new report from KLAS Research. The report found that physicians with ambulatory EMR software say EMRs lack a number of functional areas, including reporting tools, patient access to medical records and the ability to share key clinical data. More than 17 percent of providers say reporting is difficult or impossible with their current tools, and another 24 percent report needing specific technical expertise to manipulate the tools provided, said Mark Wagner, KLAS director of ambulatory research and author of the new report.

Here’s an example of how a registry can improve care for chronic conditions. Two years ago, Apple Valley Medical Center, one of six clinics participating in Medica’s clinic-based chronic care management program, developed a registry of its patients with diabetes to allow the clinic to track them better. The registry provides staff with daily reminders on patient status so that any issues are addressed promptly. Based on the issue, the provider involved may be a nurse, nurse practitioner, physician or other provider. As a result of this approach, Apple Valley Medical Center was able to improve its community standing on this measure by 110 percent in the first year of the program. Its patients with diabetes “at goal” for optimal diabetes care, as reported to Minnesota Community Measurement, moved up 23 percentage points in one year.

According to a new national study by the Center for Studying Health System Change, only four in 10 of primary care physicians whose practices care for patients with four common chronic conditions—asthma, diabetes, congestive heart failure and depression—were in practices using registries to keep track of patients with chronic conditions.

Dr. Judith Hibbard, professor of health policy at the University of Oregon and developer of the Patient Activation Measure™ (PAM), answers the question of whether or not patient activation can be measured.

We started out the process of defining activation by first asking whether it is something that we can measure. The first step was to get some clarity on the definition of activation because people use the term loosely. We went through a rigorous process that included reading the literature, holding patient focus groups and having expert consensus panels. For all of those groups we asked the question, what does it take to manage successfully when you have a chronic illness? We did have some consensus in answering that question; however, the definition that emerged was that people need to believe that they have a role to play in self-management, in collaborating with their provider and in taking preventive action. They also need to have some skill and confidence.

We used a process called Rasch analysis for our measurement, which is used when more precise and consistent measurement is important. This process yields a measurement that is stronger, more precise and consistent than most social science-based measures. The analysis consists of short and tall bars that represent the difficulty structure of the measure. There are 13 questions, with each question having a calibration  how hard it is for most people to admit if something is true about them or not. The short bars represent those people who can say that something is true about them and the tall bars represent those people who can’t. This difficulty structure is quite robust. We have had the measures translated into 15 languages. We have evaluated the results of about six of those translations. This difficulty structure is maintained across language and culture.

The other characteristic of the measurement that is important and different is that we seem to be tapping into one underlying idea, even though there are 13 different questions. We think the underlying idea is, “I understand what my job is and I feel able to do it.” That is important because it can allow us to predict how people will behave in different situations. If you can imagine having measurement on someone’s self-esteem, and if you knew their level of self-esteem, you could predict how they might behave in different situations. That is the same with the PAM. It is tapping into an underlying idea that tells us about people’s behaviors.

After looking at the measurement, we were able to see that it looks like people go through different phases or levels on their way to becoming effective self-managers. We have conducted in-depth interviews with people at these different levels and what we see is that people at the low end are discouraged. They have had many experiences with failure. They feel overwhelmed with the job of managing their health. They have low confidence in themselves and they become passive. Some of them may not recognize that their job is to manage their health. At the high end of activation, we have the opposite. People are very proactive and goal-oriented. They also have good problem-solving skills, which is something that the individuals at the low-end do not have.

Imagine someone at the low end of activation, who has a chronic illness, going in to see their clinician. They are told that they have to change many different things about their lifestyle. What happens? They feel overwhelmed. They might try to do it, but they can’t. By not understanding what is going on with that person, the clinician may be helping to keep that person in a low activation state.

Of 1.8 billion prescriptions dispensed annually in the U.S., only 50 percent are taken correctly, says the WHO. A review of HEDIS data reveals that 55,000 deaths could be avoided each year by improving medication management of chronic conditions — especially hypertension and diabetes, as we learned last week from Dr. Beth Chester of Kaiser Permanente (KP).

In response to escalating cost and utilization tied to poor medication adherence, the healthcare industry is beginning to hold organizations more accountable for practices in this area. About a third of objectives proposed by CMS this month to demonstrate meaningful use of EHRs are related to the electronic documentation and prescribing of medications, with the care goals of improving quality, safety, efficiency and reducing health disparities.

Two newer HEDIS metrics — one related to medication reconciliation post-discharge and the other involving medication review in the elderly — only give health plans credit when these activities are performed by a prescribing practitioner or a clinical pharmacist, Dr. Chester explained during a conference on medication therapy management in the patient-centered medical home. She said healthcare utilization and costs for KP’s patients with targeted chronic illnesses diminished drastically once pharmacists stepped in to review medications, adding that “accrediting organizations such as NCQA have begun to recognize pharmacist’s expertise when it comes to medication review and reconciliation.”

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